Understanding long-term care

Find out what the alter­na­tives are for such step-​down care or what is termed long-​term care.

BY: Eddy Cheong

At the National Day rally this year, Prime Min­is­ter Lee Hsien Loong said that the Gov­ern­ment is gear­ing up to pre­pare for an age­ing pop­u­la­tion and one of the key ini­tia­tives would be the expan­sion of the step-​down care for our elderly. This is a crit­i­cal area of our health­care sys­tem as more peo­ple move out of the acute hos­pi­tals but con­tinue to need a cer­tain level of med­ical care.

Long-​term care or LTC is not about short-​term reha­bil­i­ta­tion or recu­per­a­tion from surgery, but rather con­tin­u­ous care over an extended period. The way to mea­sure LTC is the Activ­ity of Daily Liv­ing (ADL). For instance, one is defined to be dis­abled in an ADL if he or she requires the help of another per­son to per­form that activ­ity, with either active or standby help. Hence, those who rely on assis­tive devices only are gen­er­ally not counted as using LTC ser­vices, because they do not require the assis­tance of another per­son. In Sin­ga­pore, one in 12 elderly suf­fers from dis­abil­i­ties as a result of age­ing and ill­ness, 3% of aged 65 and above were not able to move by them­selves while another 8% need help with ADLs.

Plan­ning for LTC

Many peo­ple fail to plan because it is an emo­tional topic and they do not want to think about it. For those who do think about it, they do not under­stand what it involves and also often under­es­ti­mate the cost of LTC. 

To under­stand why plan­ning is so impor­tant, let’s look at some key sta­tis­tics locally: A good 10 per­cent of peo­ple above 65 in Sin­ga­pore need some form of assis­tance and this is rat­i­fied by stud­ies in the US where there is a 40 per­cent chance of some­one who reaches the age of 65 to enter in a nurs­ing home.

Start today to under­stand and plan for the pos­si­bil­ity of one of your aged par­ent or rel­a­tive who might need LTC and reduce the emo­tional and finan­cial stress when it does hap­pen. With the ris­ing cost of health­care, you want to be pre­pared finan­cially by either set­ting aside the nec­es­sary funds or buy­ing the right insur­ance. With a plan in place you would also have more con­trol and choice over when and how to obtain LTC services.

The infor­ma­tion fol­low­ing would give you a good han­dle of what is avail­able and get you off to the first start.

LTC facil­i­ties & support

There are sev­eral options to receiv­ing LTC ser­vices. It can be through an insti­tu­tion or from the fam­ily, which depends on the individual’s pref­er­ence, degree of care and finan­cial ability.

Essen­tially each cat­e­gory can be sum­marised as follows:

INSTITUTIONAL-​BASED (RES­I­DEN­TIAL) FACILITIES

As the name sug­gests, institutional-​based facil­i­ties are those care­giv­ing that are pro­vided through insti­tu­tions. In the Asian con­text, this seems as an unde­sir­able option as patients would gen­er­ally pre­fer to stay with their own fam­i­lies and the Gov­ern­ment is also encour­ag­ing “ageing-​in-​place”.

Min­is­ter Lim Boon Heng explained this con­cept dur­ing a pub­lic forum in Sep­tem­ber, “Ageing-​in-​place involves enabling the elderly to age in the home he has grown old in, in the com­mu­nity he is famil­iar with. For those who are more frail, with lim­ited mobil­ity and need­ing care, we are expand­ing efforts to make our liv­ing envi­ron­ment barrier-​free and to pro­vide the social and com­mu­nity ser­vices to sup­port them at home. For those with ter­mi­nal con­di­tions, ageing-​in-​place involves prepar­ing well so that the patient remains in the com­forts of his home and there is no unin­formed rush to the hos­pi­tal for emer­gency treatment.”

Here are the options:

• Nurs­ing homes – Nurs­ing homes pro­vide long-​term skilled nurs­ing care for elderly patients. This option is usu­ally for those who do not have fam­i­lies or the fam­ily mem­bers are unable to pro­vide the level of care needed.

Patients who are eli­gi­ble for Min­istry of Health (MOH) sub­si­dies are placed by the Inte­grated Care Ser­vices into VWOs (Vol­un­tary Wel­fare Organ­i­sa­tions) and selected pri­vate nurs­ing homes under the MOH portable sub­sidy scheme. Patients who are not eli­gi­ble for sub­si­dies can also admit them­selves into any nurs­ing home. Cost can range from $1,300 per month for eight-​bed room to as high as $4,000 for a sin­gle bed room.

• Chronic sick hos­pi­tals – These hos­pi­tals pro­vide long-​term skilled nurs­ing care for elderly patients with advanced, com­pli­cated and med­ical con­di­tions that require greater super­vi­sion than those in nurs­ing homes. Such ser­vices usu­ally cost more and can range from $1,900 to $6,400 depend­ing on the type of care required and the qual­ity of accommodation.

• Respite care – This option pro­vides short-​term cus­to­dial care for patients who exhibit chal­leng­ing behav­iour. It also helps care­givers, who after a pro­longed period of care giv­ing, to receive some short-​term respite, for exam­ple, vaca­tion or time out. Daily rates are usu­ally about $80 to $90 per day for a nine-​bed room to $130 and above for sin­gle bed room.

HOME-​BASED (COMMUNITY-​BASED) FACILITIES

For those patients who are being cared by their fam­i­lies, there are sev­eral home-​based ser­vices avail­able for the care­givers to rely on:

• Care by fam­ily – This seems the pre­ferred option for patients here. For care­givers who require nec­es­sary knowl­edge and skills in care­giv­ing, exter­nal courses and train­ings are avail­able. Eli­gi­ble care­givers can receive a Care­giver Train­ing Grant of up to $200 per year (from the National Coun­cil of Social Service).

Fam­i­lies may also con­sider hir­ing a for­eign domes­tic worker to pro­vide addi­tional help. Cost of domes­tic help includ­ing For­eign Wage Levy would range about $600 to $700.

• Home med­ical – Usu­ally com­prises of a team includ­ing a doc­tor, nurse and social worker to pro­vide ongo­ing holis­tic care to the home­bound through reg­u­lar home vis­its. Frail or bedrid­den older patients who have mul­ti­ple med­ical or nurs­ing needs with per­ma­nently dis­abil­ity or unable to leave the flat would be suit­able for this ser­vice. A refer­ral from a doc­tor or hos­pi­tal is needed. Cost is about $200 to $350 per visit.

• Home nurs­ing – House-​bound or bedrid­den older patient who require nurs­ing pro­ce­dures will require home nurs­ing. Such care includes wound dress­ing, injec­tions and change of feed­ing tube. A refer­ral from a doc­tor or hos­pi­tal is needed. Cost is about $200 to $350 per visit.

ICS & means testing

For those who need finan­cial assis­tance, they would come under the purview of ICS. They are a cen­tral body that man­ages and coor­di­nates refer­rals and step-​down facil­i­ties to ensure seam­less flow of ser­vices to patients who leave the hos­pi­tals. Pre­vi­ously, means-​testing would deter­mine four level of sub­si­dies a patient will get if he or she needs step-​down ser­vices. How­ever if a patient requires care in com­mu­nity hos­pi­tals, the sub­sidy would be expanded to nine lev­els from 1 Octo­ber 2009 in view of rel­a­tively huge bills. With this enhance­ment, MOH esti­mates that one in two sub­sidised patients would pay less.

Gov­ern­ment sub­sidy for LTC ser­vices (except com­mu­nity hospitals):

Although this is an emo­tional topic but it is pre­cisely of this that you should start talk­ing to your elderly par­ents and rel­a­tives about what would be accept­able level of care for them in the unfor­tu­nate sit­u­a­tions need­ing LTC. In fact, you should also be think­ing about what level of care you would like to have for your­self as well. Decide on the level of care today and start deter­min­ing if you need to set aside the cash or buy the right insur­ance so that you do not have to com­pro­mise when the sit­u­a­tion happens.

Eddy Cheong is the head of risk man­age­ment and finan­cial plan­ning at Prov­i­dend Ltd. He is also a trainer at Prov­i­dend Cen­tre of Finan­cial Edu­ca­tion (PCFE), which brings finan­cial knowl­edge to peo­ple of all life stages and from all walks of life. Visit us at www​.prov​i​dend​-cfe​.com or e-​mail us at info@​providend-​cfe.​com. 

(PHOTO CREDIT: Providend)